CAPITULO III MARCO JURÍDICO
3.5. Precedentes administrativos sobre clasificación arancelaria
Shinebourne and Smith (2011) remind us about the fact that "recovery from addiction is more than not using drugs or alcohol in an otherwise unchanged life". Recovery in a broader sense is also about "developing new skills and values and forming new identities and new life projects, with or without support from treatment or self-help organizations". Recently, Blok (2011) has reviewed the history of the Dutch addiction care. Her historical review clearly confirms that the Dutch addiction care has a strong tradition in keeping addicts, as much as possible, socially integrated. However, Blok (2011) concludes that during its century of history the Dutch addiction care has played a double role: on the one hand adapting society to addicts, but on the other hand adapting addicts to society. The history of a century of Bouman GGZ, the regular institute for addiction care in the area of Rotterdam, has been described separately by Van der Stel (2010b).
In February 2006, the national government and the municipalities of the four largest cities of the Netherlands signed and funded the "Strategy Plan for Social Relief" for the group of homeless people with complex and persistent problems (Plan van Aan- pak Maatschappelijke Opvang). Problem alcohol and/or drug use counts as one of the major persistent problems among the homeless, but no recent updates are available about the proportion of homeless people abusing alcohol and/or drugs. By the end of 2010, a total of 12,436 homeless people were targeted in the four largest cities, of whom 7,476 people reached a "stable mix". A stable mix requires a stable living situation, a secure legal income, and a stable contact with treatment (Tuynman et al 2011). Apart from the four largest cities, the Strategy Plan for Social Relief has also been implemented since 2008 in the other 39 Dutch centre municipalities (centrumgemeenten) that capture the rest of the country. In total, the Netherlands is covered by 43 centre municipalities. Quantitative results from the 39 cities are expected in the near future (Planije and Tuynman 2011).
In April 2011, the national government and the four largest cities launched the second phase of the Strategy Plan (Rijk and Vier grote steden 2011). The government concluded that the Plan was a success. Whereas the first phase of the Plan targeted the actual homeless, the second phase of the Plan will now prevent homelessness among people who are at risk to become homeless. Drug abuse has been identified as specific risk factor. The second phase of the Plan also includes relapse prevention among people
who have been homeless in the past. The second phase of the Plan has adopted a com- munity approach. However, people who stay illegally in the Netherlands and people who come from other Member States of the European Union are not subject to the Plan. It is estimated that in 2009 there were 97,145 illegal immigrants in the Netherlands (Van der Heijden et al 2011). Just as the first phase of the Strategy Plan, the results of its second phase will be monitored by the Strategy Plan for Social Relief Monitor. This monitor is conducted by the Trimbos Institute, Netherlands Institute of Mental Health and Addiction.
Programs advertised in annual reports
As a reflection of the national social relief strategy, institutes for addiction care can be found to advertise in their annual social reports special programs that aim at the social reintegration of drug users. Table 8.2.1 reviews the social-reintegration programs as published in the annual reports. All care institutions in the Netherlands are legally obliged to prepare a social report each year, on behalf of the Admittance of Care Institutions Act (in Dutch: Wet Toelating Zorginstellingen, WTZi). In case an institute for addiction care does not pay special attention to a certain rehabilitation program in its annual social re- port, this does not mean that the institute has no such program at all. An institute does mention a program in its social annual report in case it has made special efforts to set up or to expand such a program.
Table 8.2.1: Programs for social reintegration as published in the annual social reports of the main regular institutes for addiction care in the Netherlands
Institute, residence,
year reported Program for social reintegration
Arkin, Amsterdam, 2010
A separate committee for the participation of the social envi- ronment of clients (Naastbetrokkenenraad)
Participation in the national project "Family in Triad" (Familie in Triade), a project which involves the social environment in treatment
Broader involvement of experts by experience Extension of supported living to 7 locations
Supporting clients who seek work by means of Individual Placement and Support (Individuele Plaatsing en Steun) Start of 45 special places for supported living in a Housing
Training Centre (Woontrainingscentrum, WTC) for living with- out using substances
A total of 20 experts by experience
Bouman GGZ, Rotterdam, 2010
An increase with 33 units to a total of 184 units for (exten- sive) supported living for chronic addicts
Integration of treatment with housing and work
Development of the Bouman Treatment Model (Bouman Be- handelmodel, BBM) as a result of ten years of innovation Integration of social reintegration within the Bouman Treat-
ment Model (BBM)
Training programs offered to all new counsellors conducted by experts by experience
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Parnassia Bavo Groep, includ- ing Brijder Verslavingszorg, The Hague, 2010
A separate foundation (Stichting Actief Talent) and special services to support social activities, labour rehabilitation, and daily activities
A separate foundation to attack stigma by means of public campaigns
A separate trademark (Indigo) to offer community approach A separate business unit (i-psy) for cross-cultural treatment
for ethnic minorities
A total of 47 places for supported living (MiCasa)
Centrum Maliebaan, Utrecht, 2010
All treatment targets at recovery and social participation of all patients
Social rehabilitation programs Community approach
Two experts by experience at two locations in the institute Verslavingszorg Noord Neder-
land, Groningen, 2010
All care targets social rehabilitation at all the life areas that have been infected by substance abuse
Start of 4 teams for Function Assertive Community Treatment (FACT)
Stichting Tactus Groep, De- venter, 2010
In case the addiction problem becomes chronic, the care tar- gets social rehabilitation, including community approach A future total of 134 places for small-scale living Places for supported living
Daily activities aimed at labour rehabilitation Labour rehabilitation by means of the project Tactory A special project for social rehabilitation
Participation of clients in projects by means of expertise by experience
IrisZorg, Arnhem, 2010
Structural integration of addiction care and social relief Community Reinforcement Approach (CRA) will be the meth-
odological guideline for all counsellors Supported living
Rehabilitation trajectories
Recovery work (Herstelwerk) in combination with Critical Time Intervention
Social rehabilitation programs for former prostitutes to offer them a sustainable alternative
More investment in experts by experience
Financial support of charity projects in which clients can par- ticipate
Emergis, Goes, 2010
Reintegration of clients in a special working place (Demontage Werkplaats Zeeland B.V., DWZ)
A total of 212 places for supported living
Appointment of four experts by experience and participation in the project National Enforcement of Expertise by Experi- ence (LIVE) which is co-ordinated by the Trimbos Institute and the Pharos Foundation
De Hoop ggz, Dordrecht, 2010
A total of 32 places for small-scale supported living A total of 80 places in the living community "Horeb" A new building for labour projects
A separate foundation for labour reintegration
Novadic-Kentron, Vught, 2010 From start to finish, treatment targets social rehabilitation and this will be monitored in the near future
A total of 10 places for small-scale living
Participation in offering interferential care (bemoeizorg) in seven centre municipalities (centrumgemeenten)
Further development of innovative Community Reinforcement Approach
Supported living by means of hostels for chronic addicts Creation of social acceptance of the social rehabilitation of
addicts by means of hostels
Recognition of expertise by experience as the third source of knowledge besides scientific knowledge and expert knowledge Taskforce for trying out new projects for social rehabilitation Introduction of Community Reinforcement Approach (CRA) in
more regions
Vincent van Gogh voor geeste- lijke gezondheidszorg, Venray, 2010
A total of 96 places for Supported Living (Huis op proef) Special centres for daily activities in co-operation with clients A special internal activity centre (Intern Activiteiten Centrum,
IAC)
A special department for prevention, information, activities and labour rehabilitation (Preventie en Informatie, Activiteitencentra en Arbeidsrehabilitatie, PIAA)
Stichting Mondriaan, Heerlen, 2010
Integrated care by means of Functional Assertive Community Treatment (FACT)
A total of ten places for social rehabilitation
A total of 257 places for supported living (Akkerweide), espe- cially for very difficult clients at the department
Co-operation with Relim, an institute for work rehabilitation Participation of experts by experience in, for example, film
projects
Source: http://www.jaarverslagenzorg.nl.
From the twelve main institutes in table 8.2.1, ten institutes mention to have given spe- cial attention to supported living. Eight institutes especially mention the participation of experts by experience. With regard to working as an expert by experience, Shinebourne and Smith (2011) notice that "[h]elping others has been described as a particularly sig- nificant element in recovery, as it is at the core of AA practices of sponsorship, volunteer- ing for service at meetings and outreach activities". Assertive Community Treatment (ACT) or Functional Assertive Community Treatment (FACT) is mentioned by eight insti- tutes. Finally, two institutes explicitly mention the involvement of the direct social envi- ronment of the client.
On the 21st of June 2011, the ACT-teams and the FACT-teams united themselves
into "F-ACT the Netherlands" (in Dutch: F-ACT Nederland). Inter alia, this new associa- tion will grant certifications to qualified (F)ACT-teams (www.f-actnederland.nl).
Evaluation research
Social relief Omnizorg in Apeldoorn
The foundation Omnizorg is in operation since September 2008 and offers social relief in the city of Apeldoorn in the province of Gelderland. Omnizorg offers daycare as well as nightcare, and is supported by two institutes for addiction care: Stichting Tactus Groep and IrisZorg. The results of Omnizorg have been evaluated in 2011 (Biesma and
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Bieleman 2011). From September 2008 up to including December 2010, Omnizorg has offered social relief to a total of 449 clients, 89% male and 11% female. From these 449 clients, 104 clients visited a safe user room, 90 clients received methadone, and 22 cli- ents received heroin-assisted treatment. With regard to addiction problems, 19% had a problem with heroin, 16% with alcohol, 14% with cocaine, 9% with cannabis, 6% with other substances, and the remaining 36% was not known to have an addiction problem.
It was found that Omnizorg had certain positive results on the target group. From the 190 clients who had used the nightcare, 47 clients (25%) were promoted to support- ed living within Omnizorg. The percentage of clients having a health insurance increased from 93% to 97%, and the percentage receiving supported living increased from 5% to 43%. The average Global Assessment of Functioning score (GAF) increased from 32.4 to 36.3. Six out of 35 respondents reported a decrease in the use of alcohol and drugs, and drug use in public places has become rare. De percentage having been in contact with the police decreased from 39% to 20%.
Hostels in the city of Utrecht
The Strategy Plan for Social Relief was developed first in the city of Utrecht and was im- plemented next in the other cities. During the period since 2006, many studies were set up in order to monitor and evaluate the hostels (see National report 2010 for the results of these studies). In June 2010 a last hostel was opened and this was the reason for an overall evaluation. It was concluded that the hostels are successful in getting most chronic drug dependent people from the street, and in reducing public nuisance. Besides, there were no unintended consequences of this measure during the past decade. Never- theless, the hostels were often realised under frequent and in many cases also fierce pro- tests from the adjacent neighbourhoods. The protests could in most cases be reduced by a combination of decisive administration, a careful choice of locations, and (most im- portant) by frequent and intense communication between neighbourhood inhabitants and other parties. The result is that there are hardly any chronic drug-using homeless people anymore in the streets of Utrecht, besides a residue group of some 100 multi-problem people who remain difficult to place for different reasons. For some of them other solu- tions will have to be found, e.g. a more recovery-driven approach when receiving addic- tion treatment (see § 5.2), or a special program of care targeting their many chronic problems (Reinking et al 2010).
To evaluate the supported living of chronic homeless addicts by means of a hostel, Muusse (2011a) has investigated whether a hostel can restrict itself to only offering basic living conditions, the so-called "bed, bath, and bread" (bed, bad en brood). Perhaps a hostel should also offer support on issues like a meaningful life (zingeving) and recovery? To answer this question, Muusse (2011a) organized a pilot for a low-threshold support group in Hostel Wittevrouwen. This is a hostel for 31 chronic homeless poly-drug users, located in the city of Utrecht. The aim of the support group was to create discussion on the use of substances and to stimulate awareness about the motives to use them. The pilot consisted of ten meetings during which twelve inhabitants participated at least once. It was found that the quality of life and being socially accepted had increased in the hostel and that the hostel gave a new perspective on the future. However, there were serious limitations on making this perspective concrete. The inhabitants of the hos- tel experienced obstacles like work not bringing up enough money, contact with family being difficult because of a lack of space to receive children, building up contact with "normal people" outside the drug scene being difficult, and continued stigma and social
exclusion from society and institutes. From the pilot, Muusse (2011a) all in all concludes that a support group can indeed be part of extending the function of a hostel by offering daily activities, meaningfulness, and a social network.
Program "Remise" in The Hague
The program "Remise" started in 2004 at the Parnassia Bavo Groep, the regular institute for mental health care and addiction care in the region of The Hague. Remise offers the second extramural phase within a two-year Placement in an Institution for Prolific Of- fenders (ISD). In this second phase of the ISD, a period of six months, a former prolific offender is being prepared for supported or self-reliant living. Remise combines the Con- tinuing Care model with the Housing First model.
Geschiere and Jansen (2011) have evaluated the Remise program on two out- come measures. The first outcome measure was "duration of staying in treatment", and the second outcome measure was "passing through successfully to supported or self- reliant living". From 2004 up to including 2008, a total of 139 clients enrolled in Remise. Their mean age was 39 years, 95.7% were male, and 50% were ethnic. With regard to the first outcome measure, it was found that, on average, the clients stayed 147 days at Remise. With regard to the second outcome measure, it was found that 45% of the cli- ents, after one or more admissions, passed through successfully to supported or self- reliant living. From the clients who were successful, 86.5% obtained self-reliant living and 11.5% obtained supported living.
Care farms
A special way to promote the social reintegration of former addicts is offered by the care farms (in Dutch: zorgboerderijen). Currently, more than a thousand care farms are in operation in the Netherlands. They have developed their own quality management sys- tem which includes the measurement of client satisfaction. Recently, the scientific evi- dence for the positive effects of the care farms has been reviewed (Elings 2011; Elings et al 2011). It is concluded that a care farm has the following therapeutic factors: "mean- ingful work and distraction", "structure and rhythm", "other environment", "social com- munity", "small-scale groups", and "acceptance by 'normal' people". Although a care farm does not show more positive effects than regular care, the authors nonetheless conclude that a care farm does have the following positive effects for a client: "a better condition", "a better appetite", "being more productive", "finding rest", "increased self- confidence and self-esteem", "increased social behavior", and "increased commitment and taking responsibility". All in all, a care farm offers a specific choice for clients who seek work and daily activities.
Addiction medicine
By applying appropriate communication skills, addiction doctors can contribute to the social reintegration of addicts. The Dutch Master in Addiction Medicine (MiAM) is a com- petency-based professional training of which "communicating adequately" counts as one of the seven qualifications. It is a full-time 2-year professional training, in operation in the Netherlands since 2007. As a goal of the training, the trainee professionally "[d]iscusses treatment options with a patient, performs shared decision making on these options, and records the option that was agreed on in the formal treatment agreement" (M. De Jong et al. 2011). Taking addicts seriously as empowered patients, not excluding them from proper care but respecting them as equal interlocutors within the doctor-
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patient relation, counts as the addiction doctor's contribution to social reintegration. C. De Jong et al (2011) have evaluated the present status of the MiAm. The evaluators "conclude that the MiAM is answering the needs of the mental health and addiction treatment field". The next step is "to become the starting point for a shared European initiative to train certified medical specialists in addiction medicine".